Credentialing Forms

If you would like to become a provider within our network, please fill out the Become A Provider form. Or call us at 1-866-282-6280 or TTY: 711.

• Allied-and Advance-Practice Nurse Credentialing Application (PDF)
• Medical Doctor or Doctor of Osteopathy Credentialing Application (PDF)
• Arkansas Total Care Personal Care Roster Template
• Arkansas State Medical Board Attestation Form 2020 (PDF)
  This form must be returned with your MD/DO Credentialing Application (PDF) i n order to complete your submission.
• Arkansas Total Care Atypical & HCBS Provider Application (PDF)